Instructions

Complete the order form below. Then the item(s) will appear at the bottom of the screen and you will be able to add them to the shopping cart. The information you enter in the form will be submitted automatically to Cascade so you do not need to fill in a separate order form.

Price:
TBD

Please select order type

To order this product, select your options from the fields above, then click to add to cart, then complete the checkout process.

Practitioner Information:

Are you submitting measurements using the OMEGA® system?

Yes

First Name:*

Last Name:*

Cascade Account Number:

Phone:*

Mobile Phone:

Email:

Contact me via:*

PhoneMobile PhoneEmail

Patient Information:

Patient ID:*

Write patient ID on cast as well. Cast will be disposed of after liner is created unless suggested other wise in the "Notes" section of this form.

Amputation Side:*

Left
Right

If Bilateral, be sure to fill out a form for each cast or shape.

Limb circumference at highest obtainable level (in inches):*

Level of measurement from distal (in inches) (max 18 inches):*

Liner Information

Quantity of this DESIGN Liner:*

WillowWood strongly recommends providing each amputee with two liners.